Bronchiectasis is a disease that is characterized by chronic dilation and widening of the smaller bronchial tubes and bronchi and destruction of the bronchial walls. It can either be congenital (such as in cystic fibrosis, the cause of almost half the cases) or acquired via recurring inflammation or infection of the airways. It can be either a localized or diffuse disease and is more common in the lower dependent lobes. Bronchiectasis often coexists with chronic obstructive pulmonary disease.
Symptoms of bronchiectasis are dominated by a productive cough with large amounts of sputum production. About three quarters of those affected will have shortness of breath and wheezing. Chest pain upon taking a deep breath, weight loss, and anemia often accompany the condition. There aren’t a lot of physical signs on examination besides the wheezes and lung crackles. The large amount of generally foul smelling sputum produced is most characteristic. Lung function testing shows an obstructive pattern and lowered oxygen levels.
Chest x-rays are often diagnostic for bronchiectasis, but a high resolution CT scan shows the characteristic changes best. Bacteria are often cultured from the sputum, necessitating antibiotic therapy. As the disease progresses, the number of respiratory infections annually increase and progressive shortness of breath becomes very limiting for the affected individual.
Treatment of acute episodes of bronchiectasis are based on antibiotics from the results of cultures of the sputum that is produced. Hemophilus influenza is the most common organism, but virtually any pathogen can be an offender. Drainage may be necessary to allow better breathing, and surgery to remove a very affected area is still done in severe cases. Complications of the disease can be quite serious and include life threatening bleeding from the respiratory passages, heart and lung failure, collapsed lungs and the inability to breathe well enough to keep oxygen levels up in the body.
There are many underwriting considerations in bronchiectasis. When the disease occurs as part of a congenital syndrome, the accompanying problem often makes the case uninsurable. These include cystic fibrosis, Kartagener’s syndrome (when it is associated with heart abnormalities), alpha-1 antitrypsin deficiency, and many immunodeficiency states. In the absence of any of these (when the disease is acquired), the degree that the lungs are affected governs a rating. Mild disease will have a small rating, where the pulmonary function tests only show early or mild abnormalities. As the disease progresses, mortality increases, to the point where severe disease (when testing is quite abnormal and when there is shortness of breath on even minimal activity) makes ratings severe.
A few other points to mention: Continued smoking with bronchiectasis accelerates the process and is not looked on favorably. Even e-cigarette use or vaping has significant consequences. Bronchiectasis does worse when a systemic disease is combined in its outcome. When active diseases such as pulmonary tuberculosis, heart failure, immunodeficiency disease and the need for oxygen coexist, the prognosis becomes quite poor.
Beyond Psoriasis
Back in 1963, the first commercials on television came out for a coal tar product named Tegrin. It was a coal tar preparation made to combat “the heartbreak of psoriasis.” The commercials have graduated to include stars (singer Cyndi Lauper among them) and biological treatments that go far beyond topical use. While psoriasis is generally a benign (if not inconveniencing and troubling) skin condition that has little mortality complications, both an extension of the disease into a systemic component and the use of medication that has significant potential side effects have to be evaluated and monitored aside from the skin component of the disease itself.
Psoriasis is a common inflammatory skin condition that is characterized by bright red plaques, generally looking like silver scales, and most often present on elbows, knees and scalp. Its major symptoms are itching and sometimes bleeding from the lesions if scratching is too intense. Psoriasis may take several forms, from the common plaque type to the eruptive type (called guttate psoriasis) to actual life threatening forms (generalized pustular psoriasis, fortunately rare). The diagnosis is generally a simple one made by a trained dermatologist.
Treatments of limited disease were with coal tar preparations, topical corticosteroids, or ointments which contain Vitamin D analogs. More moderate disease was often amenable to Ultraviolet light phototherapy. Generalized disease (more the “heartbreak” type) was treated with photochemotherapy and drugs originally used in the diagnosis of cancer or neoplastic disease (like methotrexate) which helped reduce skin turnover and the severity of scaling. The drugs however had significant side effects (long term methotrexate for instance was associated with the development of liver cirrhosis) and this mode of therapy is now rarely used.
At times psoriasis is accompanied by systemic symptoms. Psoriatic arthritis is a symmetric polyarthritis that mimics the more severe rheumatoid arthritis. Fewer joints are involved with psoriatic arthritis, but joint destruction can occur in both conditions. Psoriasis generally proceeds the arthritis in most cases, and the severity of the skin disease mirrors the severity of the arthritis. Joint pain is a common finding, and lab tests aren’t always specific for the disease. Severe cases may be accompanied by anemia and spinal involvement.
Newer medications have come out to treat psoriasis and belong to a class of drugs known as tumor necrosis factors (TNF). They include medication known more commonly by their trade names of Humira, Enbrel and Remicade. The medications have significant side effects and have to be monitored carefully. Newer medications such as Otezla and Stelara are often being used even for what are characterized as “resistant” cases of psoriasis even when there is no systemic involvement, and in effect they are cosmetic treatments.
Additionally, older patients who take the medications have a high prevalence of polypharmacy effects, with medications being used for different conditions interacting with the ones given for psoriasis. The medications are directly advertised via television and journal advertisements directly to the consumers, and many now ask their doctors for the drugs at the first sign of a persistent skin condition. While they have a good degree of effectiveness, the side effects of even the newer medications must be watched for closely.
Most cases of psoriasis are not ratable. When psoriatic arthritis and other systemic conditions coexist, the disease is underwritten for the underlying condition. Those under treatment with biologics must be followed regularly for potential side effects from their medication.